1. Cholinesterase inhibitors
Huda Etoom

2. Mechanism of action
Cholinesterase is enzyme that cleaves acetylcholine to acetate and choline to end its action , It’s located in both pre and postsynapse.
Cholinesterase inhibitors inactivate acetylcholinesterase by reversibly binding
to the enzyme.
Cholinesterase inhibitors indirectly provide a cholinergic action by prolonging the life time of acetylcholine
Clearance is due to both hepatic metabolism (25–50%) and renal excretion (50–75%).

3. Effect on different organ systems:
Cardiovascular receptors— The predominant muscarinic effect on the heart is
bradycardia that can progress to sinus arrest.
Pulmonary receptors— Muscarinic stimulation can result in bronchospasm
(smooth muscle contraction) and increased respiratory tract secretions.
Gastrointestinal receptors— Muscarinic stimulation increases peristaltic
activity (esophageal, gastric, and intestinal) and glandular secretions (eg,
salivary). Postoperative nausea, vomiting, and fecal incontinence have been
attributed to the use of cholinesterase inhibitors
Eye_ Miosis

5. Classified to:
Reversible: Neostigmine , physostigmine, pyridostigmine, Endrophnium
Irreversible: Isoflurophate, Echothiphate

6. Specific Cholinesterase Inhibitors NEOSTIGMINE
Polar/lipid insoluble: doesn’t enter the CNS
Dosage & Packaging :The maximum recommended dose of neostigmine is 0.08 mg/kg (up to 5 mg in adults), but smaller amounts often suffice and larger doses have also been given safely.
Some clinicians use a dose of 0.04 mg/kg (or 2.5 mg) if the preexisting blockade is mild to moderate and a dose of 0.08 mg/kg (or 5 mg) if intense paralysis is being reversed; other clinicians use the “full dose” for all patients.
The effects of neostigmine (0.04 mg/kg) are usually apparent in 5 min, peak at 10 min, and last more than 1 h.

7. Clinical uses
Primary action? at the end of operation available to compete with the nondepolarizing agent, thereby reestablishing normal neuromuscular transmission
Note: any prolongation of action of a nondepolarizing muscle relaxant from renal or hepatic insufficiency will probably be accompanied by a corresponding increase in the duration of action of a cholinesterase inhibitor.
It can be used for urinary retention resulting from general anesthesia
In the treatment of myasthenia gravis

8. Side Effects Salivation Bradycardia, decrease blood pressure
abdominal pain , nausea
bronchospasm ,
urinary urgency
Meiosis
Sweaty skin

9. Role of neostigmine in anesthesia
Generally: side effects of cholinestrase inhibitors are minimized by prior or concomitant administration of an anticholinergic agent.
Neostigmine increase amount of Ach so Ach competes with non depolarizing drugs and decrease their effect but leads to many side effects resulting from increased Ach concentration and activation of parasympathetic system leading to bradycardia ,meiosis, hyper-salivation,intestinal hypermotility so we combine atropine with neostigmine in one syringe to counteract the side effects.

11. Pyridostigmine ; slower onset and less potent
Edrophonium : less potent but the most rapid onset of action and shortest duration .
Physostigmine ; lipid soluble so can cross BBB(the only one)

12. Thank you